Provider Demographics
NPI:1154399723
Name:MORAN, LISA ANN (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:MORAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 CHALLENGER WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5441
Mailing Address - Country:US
Mailing Address - Phone:707-565-4970
Mailing Address - Fax:707-565-5183
Practice Address - Street 1:2225 CHALLENGER WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5441
Practice Address - Country:US
Practice Address - Phone:707-565-4970
Practice Address - Fax:707-565-5183
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD242662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276098Medicaid
H93816Medicare UPIN
OR276098Medicaid